Lecture 3 (Concussion)- Exam 1 Flashcards
Concussion Recognition
* If an athlete (or anyone) has an impact to the head or body and complains of what? (6)
- Headache
- Dizziness
- Trouble with noise or light
- Emotion Lability
- Trouble with memory
- Feeling “foggy”
You feel that something isn’t quite right with your athlete, student, teammate, or patient.
Increased recognition of CTE and ALS in NFL athletes
* What is CTE?
* Dx how?
* What is the generally found in alzheimer’s disease?
* This build up has been found in who?
- CTE: Chronic Traumatic Encephalopathy
- Diagnosed post-mortem as a massive buildup of tau protein in neurofibrillary tangles distributed in a unique pattern
- Absence of the buildup of beta amyloid generally found in Alzheimer’s Disease
- This build up has been found in 110 of 111 NFL athletes that were studied by McKee
There was an issue with this study
Increased recognition of CTE and ALS in NFL athletes
* What does ALS stand for?
* What is ALS?
* Who was dx with this?
- ALS: Amyotrophic Lateral Sclerosis is commonly referred to as Lou Gehrig’s disease
- A progressive neurodegenerative disease that causes motor neurons in the body to fail
- 28 former NFL players have been diagnosed with this condition that has an incidence of 1 in 100,000
Not black and white
* We do not know what?
* We do know what?
- We don’t know the long term effects of concussion
- We do know the short term effects or symptoms
What is the def of concussion (2002)
Concussion is caused by a direct blow to the head, neck or body that results in a rapid onset of symptoms that may not involve loss of consciousness. This condition gradually resolves in a sequential course. It involves a functional disturbance of brain function with grossly normal structural neuroimaging findings.
What were key points from 10 systematic reviews? (4)
- Sport specific interventions
- SCAT 6 used up to 72 hours
- SCOAT and child SCOAT
- Neurocognitive tests should not be used in isolation
Advanced Neuroimaging, Biomarkers and emerging technologies need more research
Key Points
* Updated what?
* WHat is there stong evidence for?
* What is beneficial in the right population?
* Ongoing debate of what?
* The decision to retire an athlete requires what?
- Updated return to learn and sport
- There is strong evidence for physical activity during recovery
- Cervicovestibular rehab is beneficial in the right population
- Ongoing debate exists on long term ramifications of concussion
- The decision to retire an athlete requires a team and is multifactorial
What is the Neurometabolic cascade?
Concussion:Neurometabolic condition
* Calcium?
* Potassium?
* Glucose?
* Blood flow?
- Calcium in the brain increases to 5X normal for up to 3 days
- Potassium increases by 4 X for up to 24 hours
- Glucose increases by 2 X during the first 20 minutes after injury
- Blood flow to the brain can drop by 20%
Neurometabolic Injury
* Immediately after the injury, release of what?
* Massive Neuronal depolarization leads to what?
* In order to maintain the neuronal membrane, what happens?
* What does this require?
- Immediately after the injury, release of neurotransmitters and ionic shifts occur
- Massive Neuronal depolarization leads to Potassium efflux and Calcium influx into cells
- In order to maintain the neuronal membrane potential Na-K pumps work overtime
- This requires ATP which comes from the hypermetabolism of glucose.
Neurometabolic Injury
* ATP must come from what?
* All this is occurring while what?
* increase what?
* Further mitochondrial dysfunction occurs leading to what?
- ATP must come from hypermetabolism of glucose
- All this is occurring while the body is decreasing blood flow to the brain
- Increased Lactic acid forms in the brain
- Further mitochondrial dysfunction occurs leading to Calcium accumulation
Concussion symptoms are caused by what?
Concussion symptoms are caused by a metabolic crisis
What is the issue with Imaging for concussion?
Biomarkers
* Biomarkers are thought to be what?
* What is a biomarker?
* What is a TBI biomarker?
* Biomarker can be found where?
- Biomarkers are thought to be the FUTURE of concussion diagnosis.
- Biomarkers: A measurable indicator of some biologic state or condition
- TBI biomarker: A protein, protein fragment, or enzyme which indicates the presence of axonal injury
- Biomarkers can be found in blood, CSF, and Saliva
Shahim et al.
* Repeated what?
* Who was the population? What was measured?
* What were the results?
Repeated studies focusing on Tau protein in Swedish professional hockey players.
250+ players from 12 teams who have blood drawn and Tau and Tau sub-units measured preseason
Results:
-Tau protein is elevated in the blood from baseline in concussed Hockey player
- This elevation correlated with the number of days to return to play
Shahim et al.
* 288 athletes longitudinal study where 105 had a concussion over 3 seasons. What was better at predicting return to play?
Neurofilament light was better than tau at predicting return to play
Nitta et al. Neurology
* What was the research about?
- Multiple potential biomarkers were drawn preseason in 857 College and High School athletes
- 43 athletes had levels drawn at 6 hours, 24 hours, 8, 15 and 45 days
- IL-6 levels at 6 hours predicted length of symptoms
What are the limiations of biomarkers? (4)
- They take a long tome to analyze
- Expensive
- Involve blood draws
- No large studies looking at the Pediatric population with mild TBI
What are the physiologic biomarkers? (3)
- Sleep
- Movement
- Heart Rate Variabiity
Diagnosis on the sideline
* What is difficult?
* What is important?
* Baseline what?
- Diagnosis of concussion is difficult
- Knowing the player is often as important as knowing what happened
- Baseline SCAT testing is important to understand the athletes level of functioning before the injury
SCAT-5
* What are the main points that the SCAT-5 look at? (6)
- Maddox: What is going on in the game?
- Symptom checklist
- Orientation
- Immediate Memory (5 words)
- Recalling three to six numbers backwards
- Balance testing
What are the sxs in concussion?
Not a Concussion…..
* Patient should not have what?
* Not swelling of what?
* No what?
- Patient should not have Physical Exam findings consistent with closed head injury
- No swelling of the head
- No depression or step off
Not a Concussion…..
* What is rare?
* Sxs should not?
* Prolonged what?
- Facial injuries are rare but are not likely indicative of further injury
- Symptoms shouldn’t get worse
- Prolonged vomiting, loss of consciousness and seizure are not common with concussion
Eye movement
* What are different eye mvts/issues? (4)
- Horizontal Pursuit (shaking of eyes)
- Horizontal Saccades (undershoot at looking at an item)
- Vertical Saccades
- Near Point Convergence (6 cm) is off in 24% according to a recent study out of CHOP
Memory testing
* What are ways to test memory? (4)
- Serial 3’s or 7’s
- 5 item recall
- Months of the year backwards
- Can be tailored to the patients age
What is ImPACT testing?
- Immediate
- Post-Concussion
- Assessment and
- Cognitive
- Testing
IMPACT Testing
* What type of test?
* How long to complete?
* Best what?
- Neuro-Cognitive computer test
- 20-25 minutes to complete
- Best concussion management tool available
IMPACT testing:
* Why is this the best tool available?
- scores have good reliability
- Used by NFL, NHL, MLB, and the NCAA
- Can be used to monitor a patients progression from concussion but the most optimal use is when compared to a players personal baseline
Uses of ImPACT
* If baseline testing is available it provides what?
* If baseline testing is not available, repeated what?
* Test scores give what?
- If baseline testing is available it provides reliable evidence of return to baseline
- If baseline testing is not available, repeated tests can help determine recovery progression
- Test scores give objective data for Physician and parent discussions
IMPACT testing
* What does program measure? (6)
- Attention Span
- Working memory
- Sustained and selective attention span
- Response variability
- Non-verbal problem solving
- Reaction time
RAW RNS
Gaudet and Weyandt, 2017
* Invalid performance incidence may increase with what?
* _
- Invalid performance incidence may increase with large group versus individual administration, use in nonclinical settings, and among those with Attention Deficit-Hyperactivity Disorder or learning disability
- Sandbagging
What are some other things people are trying to validate? (2)
- Pupillometry
- EEG
Prevention
* Specialized what?
* Most concussion happen when?
- Specialized helmets and headbands have not been shown to decrease concussion
- Most concussions happen secondary to rotational forces
Collar:
* What does the collar do?
* Concept is what?
* No studies on what?
- A collar that compresses the internal jugular vein increasing volume of the brain
- Concept is decreased movement with impact
- No studies to show decrease in concussion
What is the data on collars?
In high school football (male) and soccer players (female) wearing a jugular collar there were no changes on DTI imaging while athletes without collars had changes in DTI even though they were symptom free at the time of evaluation
What decreases concussion in hockey?
MOUTHGUARDS
Alterations in play
* Removal of what?
* Limiting what?
- Removal of checking from youth hockey has led to a 58% decrease in concussion
- Limiting contact in practice in American football could decrease the rate fo concussion by 64%
Linear vs. Rotational forces
* Majority of concussions in the NFL were caused by what?
* In Taekwondo, what is most likely to cause an concussion?
* There is ongoing research about what?
- Majority of concussions in the NFL were caused by hits to the side of the helmet
- In Taekwondo the hook kick is the most likely to cause concussion
- There is ongoing research using a variety of methods to measure linear and rotational forces required to cause a concussion
So you have a concussion….What do we do?
* Most do what?
* What should you limit?
So you have a concussion….What do we do
Concentrate on the student-athlete:
* What do you need to do slowly?
* offer what?
* What needs to happen in planned progression?
* Do not take what?
- return to learning slowly
- Offer accommodations meant to make school more bearable (seating, lights, notes, etc.)
- make up work in a planned progression
- Don’t take tests until fully cleared
What is the Return to sport in gradual fashion (AT-18)?
- Day 1: Light Aerobic activity (HR <70%)
- Day 2: Non-Contact Drills
- Day 3: Complex non-contact drills
- Day 4: Full contact practice
- Day 5: Return to play
What do you do about 3 weeks out?
This is the time where we think about:
- Vestibular Therapy
- Medications
- Other medical issues
- Psychiatric confounders
How many is too many concussions?
- We don’t know
- 2nd concussion in one season
- 3rd in a year
- No lifetime maximum but we need to watch for patterns of injury
